Summary Report for FSPSAs Ending During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 07-01-22 and 09-30-22 Date of Report: 10-19-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 337 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 10 10 7.761111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 10 7.761111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 4 1.811112 $87.8400 $48.5000
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Subtotal (Total Children Is Unduplicated) 3 4 1.811112 $87.8400 $48.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.700000 $3500.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.066667 $15.4500 $231.7400
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.233333 $61.6700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.450000 $72.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 24 30.844445 $1542.2300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 19 19 16.466668 $823.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 9.898413 $247.4600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 22.060317 $1103.0100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 6 6 22.030952 $1101.5500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 9.972222 $498.6100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 10 10 9.683334 $484.1700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.000000 $25.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 276.285715 $13814.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 13.000000 $650.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 168 219 1047.115080 $10471.1500 $10.0000
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 0.500000 $35.9800 $71.9600
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Subtotal (Total Children Is Unduplicated) 197 323 1463.307146 $34496.3900 $23.5700
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Total 337 1472.879369 $34584.2400 $23.4800
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Number of Children (Unduplicated) With at Least One Authorization 206